Predicting the impact of climate change on the potential distribution of the invasive tomato pinworm Phthorimaea absoluta (Meyrick) (Lepidoptera: Gelechiidae)

Phthorimaea absoluta (Meyrick) (= Tuta absoluta) (Lepidoptera: Gelechiidae), is the most damaging insect pest threatening the production of tomato and other solanaceous vegetables in many countries. In this study, we predicted the risk of establishment and number of generations for P. absoluta in the current and future climatic conditions under two Shared Socioeconomic Pathways (SSP2-4.5 and SSP5-8.5) of the years 2050 and 2070 using insect life cycle modelling (ILCYM) software. We used a temperature-dependent phenology model to project three risk indices viz., establishment risk index (ERI), generation index (GI), and activity index (AI) based on temperature data. The model projected large suitable areas for P. absoluta establishment in the Southern hemisphere under current and future climatic scenarios, compared to the Northern part. However, the risk of P. absoluta is expected to increase in Europe, USA, Southern Africa, and some parts of Asia in the future. Under current conditions, P. absoluta can complete between 6 and 16 generations per year in suitable areas. However, an increase in GI between 1 and 3 per year is projected for most parts of the world in the future, with an increase in AI between 1 and 4. Our results provide information on the risk of establishment of P. absoluta which could guide decision-makers to develop control strategies adapted for specific agro-ecological zones.

Forest disturbance and recovery in Peruvian Amazonia

Amazonian forests function as biomass and biodiversity reservoirs, contributing to climate change mitigation. While they continuously experience disturbance, the effect that disturbances have on biomass and biodiversity over time has not yet been assessed at a large scale. Here, we evaluate the degree of recent forest disturbance in Peruvian Amazonia and the effects that disturbance, environmental conditions and human use have on biomass and biodiversity in disturbed forests. We integrate tree-level data on aboveground biomass (AGB) and species richness from 1840 forest plots from Peru's National Forest Inventory with remotely sensed monitoring of forest change dynamics, based on disturbances detected from Landsat-derived Normalized Difference Moisture Index time series. Our results show a clear negative effect of disturbance intensity tree species richness. This effect was also observed on AGB and species richness recovery values towards undisturbed levels, as well as on the recovery of species composition towards undisturbed levels. Time since disturbance had a larger effect on AGB than on species richness. While time since disturbance has a positive effect on AGB, unexpectedly we found a small negative effect of time since disturbance on species richness. We estimate that roughly 15% of Peruvian Amazonian forests have experienced disturbance at least once since 1984, and that, following disturbance, have been increasing in AGB at a rate of 4.7 Mg ha-1  year-1 during the first 20 years. Furthermore, the positive effect of surrounding forest cover was evident for both AGB and its recovery towards undisturbed levels, as well as for species richness. There was a negative effect of forest accessibility on the recovery of species composition towards undisturbed levels. Moving forward, we recommend that forest-based climate change mitigation endeavours consider forest disturbance through the integration of forest inventory data with remote sensing methods.

Socio-cultural practices on the use of beetle grubs as food and feed in western Kenya

We examined the socio-cultural practices on the use of beetle grubs as food and feed in western Kenya by interviewing 211 randomly selected households and conducting seven focus group discussions in Bungoma, Kakamega, Busia, and Trans Nzoia counties. The grubs were used as food and feed in ~ 39% and 78% of the households, respectively. The perceived benefits of the grubs for human consumption were nutritiousness and no linkage to allergies. The grubs were perceived to enhance animal weight gain and increase poultry egg laying. They were also perceived to recycle nutrients from organic waste, and clean the environment. Toasting and roasting were the dominant methods of preparing the grubs. Lack of knowledge on the grub nutritional benefits and stigma were key deterrents to their consumption. About 66% of the respondents expressed willingness to farm the grubs if the market and rearing protocols are available. Almost 98% of the respondents lacked knowledge of the beetle biology, indicating limited capacity to conserve them. The practices on the use of beetle grubs as food and feed differed across counties and by gender, age, marital status and education level. Strategies for sustainable use of the grubs as food and feed have been proposed and new research directions highlighted.

Characterization of Viruses in Phase 3 and Phase 3b Trials (the Ring Study and the Dapivirine Ring Extended Access and Monitoring Trial) of the Dapivirine Vaginal Ring for Human Immunodeficiency Virus Type 1 Infection Risk Reduction

BACKGROUND

The Ring Study demonstrated 35.1% human immunodeficiency virus type 1 (HIV-1) infection risk reduction among participants who used the Dapivirine vaginal ring-004 (DVR), whereas the Dapivirine Ring Extended Access and Monitoring (DREAM) trial, approximated a 62% risk reduction. The observed non-nucleoside reverse-transcriptase inhibitor (NNRTI) resistance-associated mutations (RAMs) and effects on viral susceptibility are described here.

METHODS

Population-based genotyping on plasma samples collected longitudinally, and next-generation sequencing (NGS) and phenotypic susceptibility testing were done on plasma collected at seroconversion. Retrospective HIV-1 RNA testing was used to more accurately establish the time of infection.

RESULTS

In the Ring Study, NNRTI RAMs were not observed in most viruses at seroconversion (population-based genotyping: DVR: 71 of 84, 84.5%; placebo: 50 of 58, 86.2%). However, more E138A was found in the DVR group (E138A DVR: 9 of 84, 10.7%; placebo: 2 of 58, 3.4%; P = .2, Fisher exact test). NGS detected 1 additional mutation in each group (DVR: G190A; placebo: G190A and G190E). Marginal dapivirine susceptibility reduction was found with NNRTI RAMs at seroconversion (geometric mean fold-change, range: DVR, 3.1, 1.3-5.1; placebo, 5.8, 0.9-120). NNRTI RAMs were not emergent between first detectable HIV-1 RNA and seroconversion when these visits differed (paired samples, mean ring use: DVR, n = 52, 35 days; placebo, n = 26, 31 days). After stopping DVR, 2 of 63 viruses had emergent G190G/A or K103K/N with V106V/M at final study visit. Resistance profiles from the DREAM trial were consistent with the Ring Study.

CONCLUSIONS

DVR showed little potential for selection of NNRTI-resistant variants.

CLINICAL TRIALS REGISTRATION

NCT01539226 and NCT02862171.

Clinical Presentation, Treatment Response, and Virology Outcomes of Women Who Seroconverted in the Dapivirine Vaginal Ring Trials-The Ring Study and DREAM

BACKGROUND

Participants with human immunodeficiency virus (HIV) seroconversion in The Ring Study, a phase 3 trial of dapivirine vaginal ring (DVR), or in the open-label extension trial dapivirine ring extended access and monitoring (DREAM) were offered enrollment in an observational cohort study (IPM 007) to assess clinical presentation and response to antiretroviral therapy (ART).

METHODS

Participants' HIV infection was managed at local treatment clinics according to national treatment guidelines. IPM 007 study visits occurred 3 and 6 months after enrollment and every 6 months thereafter. Assessments included plasma HIV-1 RNA, CD4+ T-cell counts, and recording of HIV/AIDS-associated events and antiretroviral use. Post hoc virology analyses were performed for participants identified with virologic failure.

RESULTS

One hundred fifty-one of 179 eligible participants (84.4%) enrolled into IPM 007; 103 had previously received the DVR in the Ring or DREAM studies, and 48 had received placebo in The Ring Study. HIV-1 RNA and CD4+ T-cell counts after 12 months' follow-up were similar for participants who used the DVR in The Ring Study and DREAM, compared to those who received placebo. Of the 78 participants with a study visit approximately 6 months after ART initiation, 59 (75.6%) had HIV-1 RNA <40 copies/mL (The Ring Study: placebo: 13/23 [56.5%]; DVR: 32/39 [82.1%]; DREAM [DVR]: 14/16 [87.5%]). Post hoc virology analysis indicated that genotypic patterns observed at virologic failure were as expected of a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen.

CONCLUSIONS

Seroconversion during DVR use did not negatively affect clinical presentation or treatment outcome. Mutation patterns at virologic failure were in line with individuals failing an NNRTI-based regimen.

CLINICAL TRIALS REGISTRATION

NCT01618058.

Low Impact of Fall Armyworm (Spodoptera frugiperda Smith) (Lepidoptera: Noctuidae) Across Smallholder Fields in Malawi and Zambia

Fall armyworm (Spodoptera frugiperda Smith), a serious pest of cereals from the Americas, has spread across sub-Saharan Africa and Asia since 2016, threatening the food security and incomes of millions of smallholder farmers. To measure the impact of S. frugiperda under different management approaches, we established on-farm trials across 12 landscapes (615-1,379 mm mean annual rainfall) in Malawi and Zambia during the 2019/2020 and 2020/2021 seasons. Here we present the results from our conventional tillage, monocrop maize, no pesticide treatment, which served to monitor the background S. frugiperda impact in the absence of control measures. Median plot-level S. frugiperda incidence ranged between 0.00 and 0.52 across landscapes. Considering severe leaf damage (Davis score ≥5), the proportion of affected plants varied between 0.00 and 0.30 at the plot scale, but only 3% of plots had ≥10% severely damaged plants. While incidence and damage severity varied substantially among sites and seasons, our models indicate that they were lower in high tree cover landscapes, in the late season scouting, and in the 2020/2021 season. Yield could not be predicted from S. frugiperda incidence or leaf damage. Our results suggest S. frugiperda impacts may have been overestimated at many sites across sub-Saharan Africa. S. frugiperda incidence and damage declined through the cropping season, indicating that natural mortality factors were limiting populations, and none of our plots were heavily impacted. Long-term S. frugiperda management should be based on Integrated Pest Management (IPM) principles, including minimising the use of chemical pesticides to protect natural enemies.

Host Plant-Based Artificial Diets Enhance Development, Survival and Fecundity of the Edible Long-Horned Grasshopper Ruspolia differens (Orthoptera: Tettigoniidae)

Wild swarms of the long-horned grasshoppers Ruspolia differens (Serville) which are widely harvested for consumption and sale in Africa are seasonal and unsustainable, hence the need for innovative ways of artificially producing the insects. We investigated the development, survival, and reproduction of R. differens in the laboratory on diets mixed with host plants [Digitaria gayana Kunth, Cynodon dactylon (L.) and Megathyrsus maximus Jacq (Poales: Poaceae); Ageratum conyzoides L. (Asterales: Asteraceae)] identified from guts of their wild conspecifics with a view to developing a suitable diet for artificial mass rearing of the edible insect. A standard diet comprising ground black soldier fly, Hermetia illucens L. (Diptera: Startiomyidae) larvae, soybean flour, maize flour, vitamin premix, and ground bones was tested for rearing R. differens as a control against the same ingredients incorporated with individual powders of the different host plants. Whereas R. differens developed more slowly in the diet mixed with D. gayana than in the control diet; its development was faster in the diet mixed with C. dactylon. Mortalities of R. differens in host plant-based diets were 42.5-52.5%, far lower than in the control diet with 71% mortality. The insects raised on the diet mixed with M. maximus laid approximately twice more eggs compared to R. differens fecundities from the rest of the diets. However, inclusion of host plants in the diets had no detectable influence on R. differens adult weight and longevity. These findings support inclusion of specific host plants in artificial diets used for mass rearing of R. differens to enhance its survival, development, and fecundity.

The costs and benefits of primary prevention of zoonotic pandemics

The lives lost and economic costs of viral zoonotic pandemics have steadily increased over the past century. Prominent policymakers have promoted plans that argue the best ways to address future pandemic catastrophes should entail, "detecting and containing emerging zoonotic threats." In other words, we should take actions only after humans get sick. We sharply disagree. Humans have extensive contact with wildlife known to harbor vast numbers of viruses, many of which have not yet spilled into humans. We compute the annualized damages from emerging viral zoonoses. We explore three practical actions to minimize the impact of future pandemics: better surveillance of pathogen spillover and development of global databases of virus genomics and serology, better management of wildlife trade, and substantial reduction of deforestation. We find that these primary pandemic prevention actions cost less than 1/20th the value of lives lost each year to emerging viral zoonoses and have substantial cobenefits.

Socioeconomic and health impacts of fall armyworm in Ethiopia

Since 2016, fall armyworm (FAW) has threatened sub-Saharan 'Africa's fragile food systems and economic performance. Yet, there is limited evidence on this transboundary pest's economic and food security impacts in the region. Additionally, the health and environmental consequences of the insecticides being used to control FAW have not been studied. This paper presents evidence on the impacts of FAW on maize production, food security, and human and environmental health. We use a combination of an agroecology-based community survey and nationally representative data from an agricultural household survey to achieve our objectives. The results indicate that the pest causes an average annual loss of 36% in maize production, reducing 0.67 million tonnes of maize (0.225 million tonnes per year) between 2017 and 2019. The total economic loss is US$ 200 million, or 0.08% of the gross domestic product. The lost production could have met the per capita maize consumption of 4 million people. We also find that insecticides to control FAW have more significant toxic effects on the environment than on humans. This paper highlights governments and development partners need to invest in sustainable FAW control strategies to reduce maize production loss, improve food security, and protect human and environmental health.

Introducing Beneficial Alleles from Plant Genetic Resources into the Wheat Germplasm

Wheat (Triticum sp.) is one of the world's most important crops, and constantly increasing its productivity is crucial to the livelihoods of millions of people. However, more than a century of intensive breeding and selection processes have eroded genetic diversity in the elite genepool, making new genetic gains difficult. Therefore, the need to introduce novel genetic diversity into modern wheat has become increasingly important. This review provides an overview of the plant genetic resources (PGR) available for wheat. We describe the most important taxonomic and phylogenetic relationships of these PGR to guide their use in wheat breeding. In addition, we present the status of the use of some of these resources in wheat breeding programs. We propose several introgression schemes that allow the transfer of qualitative and quantitative alleles from PGR into elite germplasm. With this in mind, we propose the use of a stage-gate approach to align the pre-breeding with main breeding programs to meet the needs of breeders, farmers, and end-users. Overall, this review provides a clear starting point to guide the introgression of useful alleles over the next decade.

Afrotropical sand fly-host plant relationships in a leishmaniasis endemic area, Kenya

The bioecology of phlebotomine sand flies is intimately linked to the utilization of environmental resources including plant feeding. However, plant feeding behavior of sand flies remains largely understudied for Afrotropical species. Here, using a combination of biochemical, molecular, and chemical approaches, we decipher specific plant-feeding associations in field-collected sand flies from a dry ecology endemic for leishmaniasis in Kenya. Cold-anthrone test indicative of recent plant feeding showed that fructose positivity rates were similar in both sand fly sexes and between those sampled indoors and outdoors. Analysis of derived sequences of the ribulose-1,5-bisphosphate carboxylase large subunit gene (rbcL) from fructose-positive specimens implicated mainly Acacia plants in the family Fabaceae (73%) as those readily foraged on by both sexes of Phlebotomus and Sergentomyia. Chemical analysis by high performance liquid chromatography detected fructose as the most common sugar in sand flies and leaves of selected plant species in the Fabaceae family. Analysis of similarities (ANOSIM) of the headspace volatile profiles of selected Fabaceae plants identified benzyl alcohol, (Z)-linalool oxide, (E)-β-ocimene, p-cymene, p-cresol, and m-cresol, as discriminating compounds between the plant volatiles. These results indicate selective sand fly plant feeding and suggest that the discriminating volatile organic compounds could be exploited in attractive toxic sugar- and odor- bait technologies control strategies.

Plant feeding as an essential resource of sand flies, primary vectors of Leishmania parasites, is largely understudied for Afrotropical species. Here, we combined field ecology, biochemical, molecular and chemical approaches, to decipher plant feeding associations in field-collected sand flies from a dry ecology endemic for leishmaniasis in Kenya revealing i) similar rates of plant feeding among sand fly sexes sampled from indoor and outdoor environments, ii) Acacia plants in the family Fabaceae as those readily foraged on by sand fly species in Phlebotomus and Sergentomyia, iii) fructose as the common sugar in sand flies and leaves of selected plant species in the Fabaceae family, iv) compounds namely benzyl alcohol, (Z)-linalool oxide, (E)-β-ocimene, p-cymene, p-cresol, and m-cresol, as discriminating volatile organic compounds between volatiles of selected Fabaceae plants. The findings indicate selective sand fly plant feeding and suggest that the discriminating volatile organic compounds could be exploited in attractive toxic sugar- and odor-bait technologies for sand fly control.

Understanding the factors affecting the humanitarian health and nutrition response for women and children in Somalia since 2000: a case study

BACKGROUND

Somalia has been ravaged by more than two decades of armed conflict causing immense damage to the country's infrastructure and mass displacement and suffering among its people. An influx of humanitarian actors has sought to provide basic services, including health services for women and children, throughout the conflict. This study aimed to better understand the humanitarian health response for women and children in Somalia since 2000.

METHODS

The study utilized a mixed-methods design. We collated intervention coverage data from publically available large-scale household surveys and we conducted 32 interviews with representatives from government, UN agencies, NGOs, and health facility staff. Qualitative data were analyzed using latent content analysis.

RESULTS

The available quantitative data on intervention coverage in Somalia are extremely limited, making it difficult to discern patterns or trends over time or by region. Underlying sociocultural and other contextual factors most strongly affecting the humanitarian health response for women and children included clan dynamics and female disempowerment. The most salient operational influences included the assessment of population needs, donors' priorities, and insufficient and inflexible funding. Key barriers to service delivery included chronic commodity and human resource shortages, poor infrastructure, and limited access to highly vulnerable populations, all against the backdrop of ongoing insecurity. Various strategies to mitigate these barriers were discussed. In-country coordination of humanitarian health actors and their activities has improved over time, with federal and state-level ministries of health playing increasingly active roles.

CONCLUSIONS

Emerging recommendations include further exploration of government partnerships with private-sector service providers to make services available throughout Somalia free of charge, with further research on innovative uses of technology to help reaches remote and inaccessible areas. To mitigate chronic skilled health worker shortages, more operational research is needed on the expanded use of community health workers. Persistent gaps in service provision across the continuum must be addressed, including for adolescents, for example. The is also a clear need for longer term development focus to enable the provision of health and nutrition services for women and children beyond those included in recurrent emergency response.

Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study

BACKGROUND

Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care.

METHODS

This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018.

RESULTS

Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services.

CONCLUSIONS

Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.

C'est vraiment compliqué: a case study on the delivery of maternal and child health and nutrition interventions in the conflict-affected regions of Mali

ABSTRACT

BACKGROUND

Mali is currently in the midst of ongoing conflicts which involve jihadist groups, rebels, and the state. This conflict has primarily centered in the North of the country. Humanitarian actors delivering services in these geographies must navigate the complex environment created by conflict. This study aimed to understand how humanitarian actors make decisions around health service delivery within this context.

METHODS

The current case-study utilized a mixed methods approach and focused on Mopti, Mali's fifth administrative region and fourth largest in population. Latent content analysis was used to analyze interview transcripts guided by our research objectives and new concepts as they emerged. Indicators of coverage of health interventions in the area of maternal and child health and nutrition were compiled using Mali's National Evaluation Platform and are presented for the conflict and non-conflict regions. Development assistance estimates for Mali by year were obtained from the Developmental Assistance for Health Database compiled by the Institute for Health Metrics and Evaluation. Administrative data was compiled from the annual reports of Mali's Système Local d'Information Sanitaire (SLIS), Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS).

RESULTS

Our data suggests that the reaction of the funding mechanisms to the conflict in Mali was a major barrier to timely delivery of health services to populations in need and the nature of the conflict is likely a key modifier of such reaction patterns. Concerns have been raised about the disconnect between the very high administrative capacity of large NGOs that control the work, and the consequent burden it puts on local NGOs. Population displacement and inaccurate estimates of needs made it difficult for organizations to plan program services. Moreover, actors delivering services to populations in need had to navigate an unpredictable context and numerous security threats.

CONCLUSIONS

Our study highlights the need for a more flexible funding and management mechanism that can better respond to concerns and issues arising at a local level. As the conflict in Mali continues to worsen, there is an urgent need to improve service delivery to conflict-affected populations.

Investigating the delivery of health and nutrition interventions for women and children in conflict settings: a collection of case studies from the BRANCH Consortium

Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.

Mapping the cattle industry in Brazil's most dynamic cattle-ranching state: Slaughterhouses in Mato Grosso, 1967-2016

The state of Mato Grosso is Brazil’s agribusiness powerhouse with a cattle herd of 30.2 million head in 2017. With land use patterns heavily influenced by beef production, which requires substantial land inputs, the state is a key target for environmental conservation. Yet the spatial and temporal dynamics of slaughterhouses in Mato Grosso remain largely unknown due to data limitations. Here, we provide a novel method to map slaughterhouse expansion and contraction. We analyzed the opening and closing of 133 plants between 1967 and 2016 in Mato Grosso and estimated the geographic locations and slaughter volumes. This was achieved by triangulating across multiple data sources including a registry of 21 million companies, government records of three million slaughter transactions (Portuguese acronym GTA), and high resolution satellite imagery. Our study is the first to include longitudinal information and both inspected (for food quality) and uninspected slaughterhouses. The results show that 72 plants operated in 2016 through 52 holding companies. By measuring geographic distances between active plants and pasture areas, we documented a 29% increase in the density of plants during 2000–2016, showing an expansion of the cattle slaughter infrastructure. We identified three periods of expansion: 1967–1995, with 15.1% of the plant openings; 1996–2003, with 24.6%; and 2004–2016, with 60.3%. While closings likely occurred throughout the period studied, no data were available prior to 2002. We estimated a minimum value for the volume of uninspected slaughter as 2–3% for 2013–2016. We conclude by discussing potential applications of the data, a deidentified version of which is made available through an online repository. The method developed here can be replicated for the whole country, which would increase our understanding of the dynamics of cattle slaughter and their impact on land use.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Incidence of induced abortion in Malawi, 2015

Background

In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates.

Methods

We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology.

Results

We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures.

Conclusions

The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.